I, ............................... S/O, W/O, D/O Shri ............................ aged ...... resident of
.................................................................... having lawful possession of the dead body of Shri/Smt./Km.
...................... S/O, W/O, D/O Shri ............................ aged ........
residen of .................................................................... having known that the deceased has not expressed any objection to his / her organ / organs being removed for therapeutic pur-poses after his / her death and also having reasons to believe that no near relative of the said deceased person has objection to any of his / her organs being used for therapeutic purposes, authorize removal of his / her body organs, namely, ...................

Signature

Date

Place

1[FORM 7][Refer rule 4(2) (b)]

I,............................... Shri/Smt./Km. ............................ having lawful possession of the dead
body of Shri/Smt./Km. ............................S/O, W/O, D/O Shri ............................ aged ..... resident
of .................................................................... after having known that no objection was expressed by
the deceased to any of his human organ being used after his death for therapeutic purposes and also having reason to believe that no near relative of the deceased person has objection to any of the deceased person's organ being used for therapeutic purposes, hereby authorize the removal of the deceased's organ, namely, ................... for therapeutic purposes.